Cost-effectiveness of first-line treatment options and treatment sequencing in advanced renal cell carcinoma

Abstract

Continued cancer research allows for the development of novel and potentially superior treatments and management approaches. The recent identification of the role of the immune system in cancer has led to the development of agents targeting the anti-tumor immune response, bringing increased survival and improved patient quality of life. However, these agents, known as immune checkpoint inhibitors (ICIs), also bring additional costs associated with the drug itself and management of immune-associated safety events. Despite the approval of three ICI-based combinations for the first-line treatment of advanced renal cell carcinoma (aRCC), the question remains as to which of the three options is the most cost effective and whether these new agents are more cost-effective overall for society. Further, given that most patients progress on first-line therapy, there is motivation in clinical practice to save ICIs as second-line salvage therapy, retaining the current non-ICI first-line standard of care. A Markov model was created comparing the costeffectiveness of these 3 ICI-based options and the current first-line standard of care in the context of multi-line treatment. The model included direct medical costs, utilities associated with progression-free survival and progressive disease, and commonly used second-line treatment options for patients who progressed on the first-line treatment options. Incremental cost-effectiveness ratios (ICERs) were calculated for all 4 first-line treatment options assessing cost (US dollars) per quality-adjusted life year (QALY). Avelumab + axitinib was the more cost effective first-line option and ICI-based combination. Only nivolumab + ipilimumab exceeded the selected willing-to-pay threshold of $100,000 USD/QALY. In summary, ICI-based combinations, in particular avelumab + axitinib, are also cost-effective first-line options in the treatment of aRCC.